TERM PAPER ON QUALITY ASSURANCE, NURSINGAUDIT,

STANDARDS AND

POLICIES

NITTE USHA INSTITUTE OF NUSING SCIENCES DEPARTMENT OF MEDICAL-SURGICAL NURSING

TERM PAPER ONQUALITY ASSURANCE, NURSINGAUDIT,

STANDARDS AND POLICIES SUBMITTED TO:MS. CLEETA SUBMITTED BY: MS. JYOTHY MATHEW

LECTURER IIND YR MSC NURSING

NUINS CON NUINS CON

SUBMITTED ON-2-9-2010

indexsl no

content

Page number

1 Quality assurance-Definition-Tools using for quality assurance-Models of quality assurance-Quality assurance process-Quality assurance in intensive coronary care unit-Research evidence

156-101013-15

2 Nursing audit-Definition-Purpose and objective-Concept of auditing-Methods of nursing audit-Audit steps-nursing audit model-Advantages-Disadvantages-Audit committee-Role of nurse-Auditing in ICU-Research studies

1617181820242526272829

3 Standards-Definition-Characterestics-Purpose-Classification of standards-Legal significance for standards-Basic standards of intensive coronary care unit.

30313132-333434-40

4 Policies-Definition-Impact-TypologiesClassification-ICU policies

4142-434545-4647-52

5 references 53

CHAPTER IQUALITY ASSURANCE

INTRODUCTION

Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources. Nursing programmes of quality assurance are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice. In addition, they motivate practitioners in nursing to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systemsThe field of quality assurance is an old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct position in the search for quality in health care.

CONCEPT OF QUALITY IN HEALTH CAREDefining quality is difficult. The expense of quality is an interactive process between customer and provider. The customer does not receive anything tangible, mostly only a piece of paper with a promise for a better future e.g. Doctors writing prescriptions. Quality

1) Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986).

2) In an economic dimension quality is the extent of accomplished relief case with a justified use of means and services (Williamson 1999)

3) Government and those who pay of the care will see quality as a weighing out between results and costs to fulfill certain expectations in health care.

CONCEPT OF QUALITY ASSURANCEQuality assurance originated in manufacturing industry. The idea was “to ensure that the product consistently achieved customer satisfaction”.Quality assurance is a dynamic process through which nurses assume accountability for quality of care they provide. It is a guarantee to the society that services provided by nurses are being regulated by members of profession.

“Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes”. (Donabedian 1982).

 “Q uality assurance as the monitoring of the activities of client care to determine the degree of excellence attained

to the implementation of the activities”. (Bull, 1985) 

Quality assurance is the defining of nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement

of client care (Maker 1998).

APPROACHES FOR A QUALITY ASSURANCE PROGRAMME

Two major categories of approaches exist in quality assurance they are

1. General 2. Specific

A. General Approach

It involves large governing of official body’s evaluation of a persons or agency’s ability to meet established criteria or standards at a given time.

1) Credentialing:It is generally defined as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency According to Hinsvark (1981) credentialing process has four functional components

a) To produce a quality product

b) To confer a unique identity

c) To protect provider and public

d) To control the profession.

2) Licensure:

Individual licensure is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice. The licensing

process requires that regulations be written to define the scopes and limits of the professional’s practice. Licensure of nurses has been mandated by law since 1903.

3) Accreditation:

National league for nursing (NLN) a voluntary organization in US has established standards for inspecting nursing education’s programs. In the part the accreditation process primarily evaluated on agency’s physical structure, organizational structure and personal qualification

4) Certification:

Certification is usually a voluntary process with in the profession. A person’s educational achievements, experience and performance on examination are used to determine the person’s qualifications for functioning in an identified specialty area.

Accrediting Agencies

a)JCAHO (Joint Commission On Accreditation Of Health Care Organization) b)NCQA( National Committee For Quality Assurance)c)ANA ( American Nurses Association )d)NAAC ( National Assessment And Accreditation Council)e)ISO ( International Organization For Stanadarization)

B. Specific approaches:

Quality assurances are methods used to evaluate identified instances of providers and client interaction.

1)  Peer review

To maintain high standards, peer review has been initiated to carefully review the quality of practice demonstrated by members of a professional group. Peer review is divided in to two types. One centers on the recipients of health services by means of auditing the quality of services rendered. The other centers on the health professional by evaluating the quality of individual performance.

2) Standard as a device for quality assurance

Standard is a pre-determined baseline condition or level of excellence that comprises a model to be followed and practiced. The ANA standard for practice includes;

Standard 1: The collection of data about health status of the patient is systematic and continuous. The data are accessible, communicative, and recorded.

Standard 2: Nursing diagnosis is derived from health status data.Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses.Standard 4: The plan of nursing care includes priorities and the prescribed nursing approaches or measures to achieve the goals derived from the nursing diagnoses.

Standard 5: Nursing actions provide for patient participation in health promotion, maintenance, and restoration.

Standard 6: Nursing actions assist the patient to maximize his health capabilities.Standard 7: The patient’s progress or lack of progress towards goal achievement is determined by the patient and the nurse.

Standard 8: The patient’s progress or lack of progress towards goal achievement directs re-assessment, re-ordering of priorities, new goal setting, and a revision of the plan of nursing care.

Standard for quality assurance

To retain the accreditation and quality of care hospitals must comply with the JCAHO (Joint Commission on Accreditation of Hospitals) quality assurance standards. The JCAHO quality assurance standard was revised in 1984, when systematic continuous monitoring and evaluating the quality of the patient care are mandatory. The nurse administrators were identified as the individual responsible for ensuring that the monitoring process is implemented.

The 6 quality assurance standards to be maintained are:

1)A planned and systematic process for monitoring and evaluating care2)Regular data collection3)The evaluation of action taken to improve care4)The documentation of findings5)The documentation of action taken6)An annual reappraisal of the hospitals quality assurance programs.

3)      Audit as a tool for quality assurance:

Nursing audit may be defined as a detailed review and evaluation of selected clinical records in order to evaluate the quality of nursing care and performance by comparing it with accepted standards. To be effective a nursing audit must be based on established criteria and feedback mechanism that provide information to providers on the quality of care delivered. To evaluate quality nursing care regularly, many staff nurses do indeed welcome opportunity to develop criteria, to review nursing care retrospectively and concurrently, and to discover methods of achieving higher levels of quality nursing care.

FACTORS CONTRIBUTING TO SUCCESS IN QUALITY ASSURANCE PROGRAM

Major factors contributing to success of quality assurance programme are:

1) Philosophy and commitment of the management2) Stability of the management and continuity of leadership for the programme3) Clarity or organization or and optimal goal4) Establishment of target yardsticks5) Involvement of employees in the respective departments in the quality assurance programme6) Motivation and commitment of the employees7) Documentation and reporting system8) Feedback systems to management and employees9) Action plans, implementation and review system 10) Incentives and recognition system

TOOLS IN QUALITY ASSURANCE

1) NURSING AUDITIt is a method of evaluating nursing care that involves reviewing patient records to assess the outcomes of nursing care or the process by which these outcomes were achieved.Successful nursing audit depend on careful nursing documentation.

2) PEER REVIEW & UTILIZATION REVIEW Peer review is an evaluation by practising nurses who have determined the standards and criteria that indicate quality care.Utilization review is a mandated reviews based on appropriate allocation of reviews , such as a review is not specifically directed to ward nursing care , but it may provide information on nursing practices that require further investigation.

3) BENCHMARKINGIt is continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers.

4) REGULATORY REQUIREMENTSJCAHO has developed standards for guide critical activities performed by the health care organizations preparation for an accreditation survey and the survey results will provide a wealth of information and data which can be utilized as ideas for improvement strategies.

5) SENTINEL EVENT REVIEWAn adverse sentinel event is an unexpected occurrence involving death or serious physical or psychological injury to a patient.Eg: serious medication errors, wrong surgical sitesDuring analysis of these sentinel events, opportunities for improving the system will arise and should be taken advantage of linkage of sentinel event review to the organization performance improvement .

6) BALANCED SCORE CARD7) BRAINSTORMING

It is a form of unrestricted, divergent thinking usually held amongst interdisciplinary groups. The topic and its scope should be well defined. Ideas and suggestions related to the topic are generated in asset time period. There is no detailed discussion on any idea advanced so as to encourage a positive approach and free flow of ideas and suggestions.

8) STORY BOARDIt is a visual display of information on flip charts or other media that all group members can see.

9) PATIENT SATISFACTION DATAMost health care facilities get feedback from patients by having them fill out a question are that asks how they felt about their health care encounter.

10) CHECK SHEETSIt is a form for gathering data that enables analysis directly from the form. The simple tick marks go to make up a stratified bar chart and help to immediately identify the problem.

MODELS OF QUALITY ASSURANCE

1) A System Model for implementation of unit Based Quality assurance:

The implementations of the unit based quality assurance program, like that of any other program, involves making changes in organizational structure and individual roles. One method of facilitating and structuring the change process is the system approach in which the task is broken down into manageable components based on defined objectives.

The basic components of the system are

a. Inputb. Throughputc. Outputd. Feedback

The input can be compared to the present state of systems, the throughput to the developmental process and output to the finished product. The feedback is the essential component of the system because it maintains and nourishes the growth. The boundaries of the system define its integration is the environment is to the other tasks and goals of nursing department, to the process of nursing science in relation to evaluation. Their boundaries should be semi-permeable so that they allow necessary information and energy into and out of the change process.

2) ANA Quality Assurance Model:

ANA quality Assurance Model was first proposed and accepted model of quality assurance by Long & Black in 1975.This helps in the self-determination of patient and family , nursing health orientation , patient’s right

The basic components of the ANA model can be summarized as follows:

i. Identify valuesii. Identify structure, process and outcome standards and criteria

iii. Select measurementiv. Make interpretationv. Identify course of action

vi. Choose actionvii. Take action

viii. Revaluate

I. Identify Value:

In the ANA value identification looks as such issue as patient/client, philosophy, needs and rights from an economic, social, psychology and spiritual perspective and values, philosophy of the health care organization and the providers of nursing services.

II. Identify structure, process and outcome standards and criteria:

 Identification of standards and criteria for quality assurance begins with writing of philosophy and objective of organization. The philosophy and objectives of an agency serves to define the structural standards of the agency. Standards of structure are defined by licensing or accrediting agency. Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns and sometimes staff assignments. Evaluation of the standards of structure is done by a group internal or external to the agency.

The evaluation of process standards is a more specific appraisal of the quality of care being given by agency care providers. An agency can choose to use the standards of care set forth by the providers professional organization such as the ANA nursing standards or the agency can use the nursing process and apply it to the activities of the nurses as the activities correspond to the procedures of care defined by the agency. The primary approaches for process evaluation include the peer review committee and the client satisfaction survey. The techniques included are direct observation, questionnaire, interview, written audit and videotape of client and provider encounter.

The evaluation of outcome standards reveals the end results of nursing care. To be able to identify the net changes in the client’s health status as a result of nursing care will give nursing profession data to show the contributors of nursing to the health care delivery system. Research studies using the trace

method or the sentinel method to identify client outcomes and client satisfaction surveys are approaches that may be used to evaluate outcome standards. Technique used is client classification systems that are admission data on the clients’ level of dependence or problems and discharge data that may show changes in the level of dependence.

III. Select measurement needed to determine degree of attainment of criteria and standards:

Measurements are those tools used to gather information or data, determined by the selections of standards and criteria. The approaches and techniques used to evaluate structural standards and criteria are, nursing audit, utilization’s reviews, review of agency documents, self studies and review of physicals facilities. The approaches and techniques for the evaluation of process standards and criteria are peer review, client satisfactions surveys, direct observations, questionnaires, interviews, written audits and videotapes. The evaluation approaches for outcome standards and criteria include research studies, client satisfaction surveys, client classification, admission, readmission, discharge data and morbidity data.

IV. Make interpretations

The degree to which the predetermined criteria are met is the basis for interpretation about the strengths and weaknesses of the program. The rate of compliance is compared against the expected level of criteria accomplishment.

V. Identify Course of Action

If the compliance level is above the normal or the expected level, there is great value in conveying positive feedback and reinforcement. If the compliance level is below the expected level, it is essential to improve the situations. It is necessary to identify the cause of deficiency. Then, it is important to identify various solutions to the problems.

VI. Choose action

Usually various alternative course of action are available to remedy a deficiency. Thus it is vital to weigh the pros and cons of each alternative while considering the environmental context and the availability of resources. In the recent that more than one cause of the deficiency has been identified; action may be needed to deal with each contributing factor.

VII. Take Action:

It is important to firmly establish accountability for the action to be taken. It is essential to answer the questions of who will do. What? By when? This step then concludes with the actual implementation of the proposed courses of action.

VIII. Re-evaluate:

The final step of QA process involves an evaluation of the results of the action. The reassessment is accomplished in the same way as the original assessment and begins the QA cycle again. Careful interpretation is essential to determine whether the course of action has improves the deficiency, positive reinforcement is offered to those who participated and the decision is made about when to again evaluate that aspect of care.

3)Plan–Do–Check–Act Cycle

Also called: PDCA, plan–do–study–act (PDSA) cycle, Deming cycle, Shewhart cycle

Description

The plan–do–check–act cycle (Figure 1) is a four-step model for carrying out change. Just as a circle has no end, the PDCA cycle should be repeated again and again for continuous improvement.

Plan-do-check-act cycle

Plan-Do-Check-Act Procedure

1. Plan. Recognize an opportunity and plan a change. 2. Do. Test the change. Carry out a small-scale study. 3. Study. Review the test, analyze the results and identify what you’ve learned. 4. Act. Take action based on what you learned in the study step: If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

4)Donabedian Model

The donabedian paradigm is recognized as a method of measuring quality as structure, process and outcome and is depicted in the linear model.

STRUCTURE

Facility,resources,philosophy,policies

PROCESS

Standards,attitudes,nursing care plan effectiveness,client satisfaction

OUTCOME

Client’s health care goals met , efficiency & effectiveness of services

FOR EXAMPLE:

5)Joint commission model

Step by step approach. Elements include

Assign responsibilityDeleniate scope of care.Identify important aspects of careIdentify indicatorsEstablish threshold for evaluationCollect and organize dataEvaluate careTake action to solve identified problem

Assess action and document improvementCommunicate relevant information to organization wide QA programme.

6)Programme evaluation model

Types

Formative evaluation.Summative evaluationComponents

Determine factors(Target population and programme) Establish purpose. Define appropriate type of evaluation. Formulate data-Gathering questions Gather data. Make a data based judgement. Formulate report

QUALITY ASSURANCE PROCESS:

1) Establishment of standards or criteria2) Identify the information relevant to criteria3) Determine ways to collect information4) Collect and analyze the information5) Compare collected information with established criteria6) Make a judgment about quality7) Provide information and if necessary, take corrective action regarding findings of appropriate

sources8) Determine ways to collect the information

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

1) Lack of Resources:

Insufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certain quality to be turned out under the prevailing circumstances.

2) Personnel problems:

Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.

3) Improper maintenance:

Buildings and equipments require proper maintenance for efficient use. If not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals.

4) Unreasonable Patients and Attendants

Illness, anxiety, absence of immediate response to treatment, unreasonable and unco-operative attitude that in turn affects the quality of care in nursing.

5) Absence of well informed population.

To improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care. This can be achieved through continuous educational program.

6) Absence of accreditation laws

There is no organization empowered by legislation to lay down standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that provides for setting of a stationary accreditation / vigilance authority to:

a) Inspect hospitals and ensures that basic requirements are met.

b) Enquire into major incidence of negligence

c) Take actions against health professionals involved in malpractice

7) Lack of incident review procedures

During a patients hospitalizations reveal incidents may occur which have a bearing on the treatment and the patients final recovery. These critical incidents may be:

a) Delayed attendance by nurses, surgeon, physician

b) Incorrect medication

c) Burns arising out of faulty procedures

d) Death in a corridor with no nurse / physician accompanying the patient etc.

8) Lack of good and hospital information system

A good management information system is essential for the appraisal of quality of care.

a) Workload, admissions, procedures and length of stay

b) Activity audit and scheduling of procedures.

9) Absence of patient satisfaction surveys

Ascertainment of patient satisfaction at fixed points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are

a) Delay in attendance by nurses and doctors.

b) Incidents of incorrect treatment

10) Lack of nursing care records

Nursing care records are perhaps the most useful source of information on quality of care rendered. The records.

a) Detail the patient condition

b) Document all significant interaction between patient and the nursing personnel.

c) Contain information regarding response to treatment

d) Have the dates in an easily accessible form.

11) Miscellaneous factors

a. Lack of good supervision

b. Absence of knowledge about philosophy of nursing care

c. Lack of policy and administrative manuals.

d. Substandard education and training

e. Lack of evaluation technique

f.  Lack of written job description and job specifications

g. Lack of in-service and continuing educational program

RESEARCH EVIDENCE

1)Quality assurance in an adult intensive care unit, Eastern region, Saudi Arabia

Abstract

Objective: Quality assurance (QA) is an increasingly important element in the administrative management of Intensive Care Unit (ICU). This is not only to improve clinical practices and patient's outcome, but also helps in proper resource utilization. We introduced a comprehensive quality assurance program in ICU at King Abdulaziz National Guard Hospital, Alhasa, Saudi Arabia, based on the existing medical evidence. Methods: We identified an already-validated set of quality indicators in intensive care and grouped them in categories of outcome measures (which reflect patient's subsequent health status) and process measures (related to patient-healthcare professional's interaction). Data collection forms were developed for nurses and physicians. Data were reported on monthly basis starting from January 2005, and the first 10 months data are presented. Results: Three hundred eighty-seven patients were admitted during the study period. Approximately 56.9% had cardiac related diseases, 33.5% had medical ailments, and 9.6% had surgery related issues. There were 54.6% males and 45.4% females. Mean age of the patients was 58.4 ± 18.3 years. The mean acute physiology and chronic health evaluation II (APACHE-II) score was 13.6 ± 4.9. Outcome measures were either better or comparable to international data, while adherence to process measures was found to be excellent. Standardized mortality ratio for the duration of study was 0.24 with 95% confidence interval from 0.15-0.36. Conclusion: Implementation of QA program is practical in an ICU. Disseminating the quality monitoring information at national level can lead to a broad data base, which can identify the best performing ICUs, thus, leading to bench marking and creating risk adjusted models applicable to local population.

2) Improving Provider-Client Communication: Reinforcing IPC/C Training in Indonesia with Self-Assessment and Peer Review - The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID)

Client communication behaviors with healthcare providersThis study used the data obtained in the Indonesia counseling, self-assessment, and peer review study to analyze what causes clients to participate actively during family planning counseling. Culturally acceptable ways for Indonesian clients to participate in consultations include asking questions, requesting clarification, stating opinions, and expressing concerns. Based on a multi-variate analysis of 1,200 counseling sessions, factors significantly associated with client active communication were, in order of importance: providers' information giving, providers' facilitative communication, providers expressing negative emotion, client educational level, and province. The study's findings reinforce the importance of achieving good provider counseling performance.

3)Restuccia ,Holloway.Methods of control for hospital quality assurance systems.Health Service Research.Vol 17(3):2000

The major failure of hospital quality assurance systems is the failure to influence physicians' therapeutic decision making in a way that will ensure their ordering necessary and only necessary services. The primary reason for this is insufficient recognition of the "intensive" technology used to treat acute patients, a technology characterized by the interdependence of therapeutic services and the patient's response to these services. In such situations, the appropriate method of achieving quality control is to provide performance feedback to the physician on a regular basis. To the extent that there is uncertainty about the impact of therapeutic services on the patient's response, the physician should be allowed discretion over the therapeutic process. In contrast, when process-outcome relations in the therapeutic process are relatively certain, feedback should be reinforced with sanctions.

4) Alfred Hospital Coronary Care Unit: an acute myocardial infarction quality assurance study.

Szto GY, Federman J, Pitt A.

Department of Cardiology, Alfred Hospital, Prahran, Victoria, Australia.

AbstractA six-month prospective study was performed to assess the efficacy of delivering thrombolytic therapy to patients with acute myocardial infarction and admitted to the coronary care unit. Patient characteristics, time from chest pain onset to presentation to emergency department, from presentation to thrombolytic therapy, transfer from emergency department to coronary care unit major interventions and outcome were assessed. One hundred and twenty patients were admitted with acute myocardial infarction, mean age 66 years (26-91), 69% were males. Of these, 50% received thrombolytic therapy. The mean time from chest pain onset to emergency department was 192 +/- 164 minutes, transfer from emergency department to coronary care unit was 195 +/- 150 minutes. The mean time from presentation to emergency department to receiving thrombolytics was 63 +/- 12 minutes. Streptokinase was the choice of thrombolytic in 97%. Thrombolytic therapy was administered in emergency department in 80% of cases. Thirty-eight (63%) patients received thrombolytic therapy within 60 minutes of presentation. Compared to the non-thrombolytic group, the thrombolytic group were younger, 63 vs 69 years, P < 0.01, presented earlier to hospital (192 vs 394 minutes, P < 0.0005), were transferred to coronary care unit sooner (195 vs 472 minutes, P < 0.001), and had more coronary angiograms (29 vs 23, P < 0.02) and PTCA performed 10 vs 3, P < 0.04. There were no significant differences in length of coronary care unit stay, length of hospital stay, patients receiving CABG or death

CONCLUSION

To ensure quality nursing care within the contemporary health care system, mechanisms for monitoring and evaluating care are under scrutiny. As the level of knowledge increases for a profession, the demand for accountability for its services likewise increases. Individuals within the profession must assume responsibility for their professional actions and be answerable to the recipients for their care. As profession become more interdependent, it appears that the power base will become more balanced, allowing individual practitioners to demonstrate their competence and expertise. Quality assurance programme will helps to improve the quality of nursing care and professional development.

CHAPTER-II

NURSING AUDITINTRODUCTION

The world trend of professional accountability to an enlightened public can no longer be ignored by nursing.Nurses easily use the words “Quality Nursing” but have nurses defined what they mean by “Quality”.Do we know their deficiencies?Are nurses ready to admit their deficiencies to their peers?Are they taking steps to remedy them?.Only by such self regulation nurses can retain their identity with the health professional as nature partners.

MEANING :

1. Quality - a judgement of what constitutes good or bad.

2. Audit - a systematic and critical examination to examine or verify.

3. Nursing audit -

(a) it is the assessment of the quality of nursing care

(b) uses a record as an aid in evaluating the quality of patient care.

4. Medical audit - the systematic, critical analysis of the quality of medical care, including the procedures for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient

DEFINITION

1)According to Elison “Nursing audit refers to assessment of the quality of clinical nursing”.

2)According to Goster Walfer

a)Nursing audit is an exercise to find out whether good nursing practices are followed.

b)The audit is a means by which nurses themselves can define standards from their point of view and describe actual practice of nursing.

BRIEF HISTORY OF NURSING AUDIT

First report of Nusing Audit of the hospital published in 1955.For the next 15 years ,nursing audit is reported from study or record on the last decade.The programme is reviewed from record nursing plan ,nurses notes,patient condition,nursing care. George Groword, pronounced the term physician for the first time medical audit. Ten years later Thomas R Pondon MD established a method of medical audit based on procedures used by financial account. He evaluated the medical care by reviewing the medical records.

First report of Nursing audit of the hospital published in 1955. For the next 15 years, nursing audit is reported from study or record on the last decade. The program is reviewed from record nursing plan, nurses notes, patient condition, nursing care.

PURPOSES OF NURSING AUDIT

1)Evaluating Nursing care given.2)Achieves deserved and feasible quality of nursing care3)Stimulat to better records4)Focuses on care provided and not on care provider.5)Contributes to research.

To measure nursing performance in practice.To assess nursing performance for reliability.To make statement about quality of nursing performance in practice.To improve future performance.To study degree of quality patient care against defined criteria.To justify cost secured on human and material sources.To take remedial measures towards effectiveness.To improve the standard of charting.

CONCEPT OF NURSING AUDITIt mainly comprises of credit and debit system

Credit system It involves mainly all positive activities in nature and its emphasis on health,knowledge in patient population,shorter stay in hospital and regular followup.Credit items are

Number of recovered patients Expansion of health knowledge in patient population. Short stay in hospital. Regular follow in community. Problem oriented care approach

Measures for improving public image Good nurses record.

debit system It involves all the negative activities in nature and emphasizes on death.Debit items are

Death of clients not justifiable Complications of disease due to neglect of nursing care. Complications of disease due to morbidity. Hospital infection Errors in treatment Clients discharged against medical advice. Absence of total patient care Lack of application of nursing process.

METHODS OF NURSING AUDIT

There are 2 methods:

a.Retrospective view-This refers to an indepth assessment of the quality after the patient has been discharged,have the patients charts to the source of data.

Retrospective audit is a method for evaluating the quality of nursing care by examining the nursing care as it is reflected in the patient care records for discharged patients. In this type of audit specific behaviors are described then they are converted into questions and the examiner looks for answers in the record. For example the examiner looks through the patient's records and asks :

a. Was the problem solving process used in planning nursing care?b. Whether patient data collected in a systematic manner?c. Was a description of patient's pre-hospital routines included?d. Laboratory test results used in planning care?e. Did the nurse perform physical assessment? How was information used?f. Were nursing diagnosis stated?g. Did nurse write nursing orders? And so on

ADVANTAGES

Comparison of actual practice to standard of careAnalysis of actual practice to standards of careIt gives total picture of the total care givenMore accurate data is available for planning action.

DISADVANTAGESThe focus of evaluation is directed away from ongoing care.

The clients problems are identified after discharge , so corrective action can only be used to to improve care of future clients.

b.The concurrent review-This refers to the evaluations conducted on behalf of patients who are still undergoing care.It includes assessing the patient at the bedside in relation to the predetermined criteria,Interviewing the staff responsible for his care and reviewing the patients recordand care plan.

ADVANTAGES

Identification of the problem at the time of care.Provision of machanisms for identifying and meeting clients need while care.Implement measures to fulfill professional responsibilities.Provision of communicating on behalf of client.

DISADVANTAGESIt is a time consuming procedureIt is not a cost effective method.It does not present total picture of care that the client ultimately will receiveIt changes the results at the expectations of care givers.

OTHER TYPESStrcture audit-The inspection of the management process as carried out and documented by the nurse manager. Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursing service, medical records and environment. This audit assumes that a relationship exists between quality care and appropriate structure. These above audits can occur retrospectively, concurrently and prospectivelyProcess audit-The inspection of the nursing process as carried out and documented by nursing staff to evaluate competence with established standards of nursing practice. Process audits are used to measure the process of care or how the care was carried out. Process audit is task oriented and focus on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care providedOutcome audit-It identifies patient satisfactory and unsatisfactory and patterns of nursing care that appears to be responsible. Outcomes are the end results of care; the changes in the patients health status and can be attributed to delivery of health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention for clients. These audits assume the outcome accurately and demonstrate the quality of care that was provided. Example of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length of hospital stay.Internal audit-It is conducted by nursing experts from within the hospital and the auditing is done in the agency or hospital.External audit-Nursing and medical administration from the ministry, other agencies or professional association.

METHODS TO DEVELOP CRITERIA

1)Define patient population.2)Identify a time frame work for measuring outcomes of care3)Identify commonly recurring nursing problems presented by the defined patient population.4)State patient outcome criteria.5)State acceptable degree of goal achievement.6)Specify the source of information7)Design and type of tool:POINTS TO BE REMEMBEREDa.Quality assurance must be a priorityb.Those responsible must implement a programme not only a toolc)A coordinator should develop and evaluate quality assurance activities.d)R oles and responsibilities must be delivered.e)Nurses must be informed about the process and the results of the programme.f)Data must be reliable.g)Adequate orientataion of data collection is essential.h)Quality data should be analyzed and used by nursing personnel at all levels.AUDIT-STEPS

Select the area of topic to be audited. Draft objective criteria for quality care. Ratify criteria. Review client record to determine whether criteria are met Analyze problems that do not meet criteria Develop solutions. Implement solutions. Evaluate and re audit Repeat cycle with drafting of new criteria.

AUDIT CYCLE

The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect.

Within the cycle there are stages that follow the systematic process of: establishing best practice; measuring against criteria; taking action to improve care; and monitoring to sustain improvement. As the process continues, each cycle aspires to a higher level of quality.

Stage 1: Identify the problem or issue

This stage involves the selection of a topic or issue to be audited, and is likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for patients. Selection of an audit topic is influenced by factors including:

where national standards and guidelines exist; where there is conclusive evidence about effective clinical practice (i.e. evidence based medicine).

areas where problems have been encountered in practice. what patients & public have recommended that be looked at. where there is a clear potential for improving service delivery. areas of high volume, high risk or high cost, in which improvements can be made.

Additionally, audit topics may be recommended by national bodies, such as NICE or the Healthcare Commission, in which NHS trusts may agree to participate. The Trent Accreditation Scheme recommends a culture of audit to participating hospitals inside and outside of the UK, and can provide advice on audit topics.

Stage 2: Define criteria & standards

Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria. These criteria are

explicit statements that define what is being measured and represent elements of care that can be measured objectively. The standards define the aspect of care to be measured, and should always be based on the best available evidence.

A criterion is a measurable outcome of care, aspect of practice or capacity. For example, ‘parents / carers are involved in negotiating or planning their child’s care’.

A standard is the threshold of the expected compliance for each criterion (these are usually expressed as a percentage). For the above example an appropriate standard would be: ‘There is evidence of parent / carer in care planning in 90% of cases’.

Stage 3: Data collection

To ensure that the data collected are precise, and that only essential information is collected, certain details of what is to be audited must be established from the outset. These include:

The user group to be included, with any exceptions noted.

The healthcare professionals involved in the users' care.

The period over which the criteria apply.

Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatical issues around data collection. Data to be collected may be available in a computerised information system, or in other cases it may be appropriate to collect data manually depending on the outcome being measured. In either case, considerations need to be given to what data will be collected, where the data will be found, and who will do the data collection.

Ethical issues must also be considered; the data collected must relate only to the objectives of the audit, and staff and patient confidentiality must be respected - identifiable information must not be used. Any potentially sensitive topics should be discussed with the local Research Ethics Committee.

Stage 4: Compare performance with criteria and standards

This is the analysis stage, whereby the results of the data collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren't met in all cases. These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.

In theory, any case where the standard (criteria or exceptions) was not met in 100% of cases suggests a potential for improvement in care. In practice, where standard results were close to 100%, it might be agreed that any further improvement will be difficult to obtain and that other standards, with results

further away from 100%, are the priority targets for action. This decision will depend on the topic area – in some ‘life or death’ type cases, it will be important to achieve 100%, in other areas a much lower result might still be considered acceptable.

Stage 5: Implementing change

Once the results of the audit have been published and discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when. Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.

Action plan development may involve refinement of the audit tool particularly if measures used are found to be inappropriate or incorrectly assessed. In other instances new process or outcome measures may be needed or involve linkages to other departments or individuals. Too often audit results in criticism of other organisations, departments or individuals without their knowledge or involvement. Joint audit is far more profitable in this situation and should be encouraged by the Clinical Audit lead and manager.

Re-audit: Sustaining Improvements

After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made. Further changes may then be required, leading to additional re-audits.

This stage is critical to the successful outcome of an audit process - as it verifies whether the changes implemented have had an effect and to see if further improvements are required to achieve the standards of healthcare delivery identified in stage 2.

Results of good audit should be disseminated both locally via the Strategic Health Authorities and nationally where possible. Professional journals, such as the BMJ and the Nursing Standard publish the findings of good quality audits, especially if the work or the methodology is generalisable.

NURSING AUDIT MODELIt consist of following aspects.1)Outcomes2)Activities3)Resources4)Cost

Relationship-Objectives

DiagnosticNursingMedicalRehabilitativePreventive

Doctors,technitians,nurses,auxiliaries

Human material and resources

Quality assurance of delivered care in relation to change in health status of the patient and cost effectiveness is the overall objective of nursing audit.Quality or excellence of delivered care is determined by patient health/ wellness outcome,

through activities and existing resources.

APPROACHES TO NURSING AUDITThis was developed by Maria Phaneuf Audit, is an audit of nursing care taken from patients notes.It includes looking for application and execution of doctors orders, observation of symptoms and reactions, supervision of patient, and care givers,reporting and recording application and execution of nursing care and promotion of physical health.The first part consist of patients details and second, evaluation of patient care.the criteria are evaluating using yes or no, certain categories and scores.

Scoring methodSCORE QUALITY OF CARE

Outcome alterations in health status of the consumer

Activities

0-4041-8081-120121-160161-200

UnsafePoorIncompleateGoodExcellent

Audit tool by joint commission for accreditation hospitalsPatients charts are reviewed according to outcome criteria and identify the complications occurred.Evaluation indicates whether complications could have been prevented and whether they were detected and managed appropriately.Audit method by hospital service of New York-It is a list of seven functions with these components and descriptive statements are developed and evaluated the care.It includes

Application and execution of doctors ordersObservation of symptoms and reactionsSupervision of patientCare giversReporting and recordingApplication and execution of nursing carePromotion of physical health.

ADVANTAGES OF NURSING AUDIT

1)Can be used as a method of measurement in all areas of nursing.2)Seven functions are easily understood.

3)Scoring system is fairly simple.4)Results easily understood.5)Assesses the work of all those involved in recording care6)May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept.DISADVANTAGES OF NURSING AUDIT

1)Appraise the outcomes of the nursing process,and it isnot so useful in areas where the nursing process has not been implemented.2)Many of the components overlap,making analysis difficult.3)It is time consuming.4)Requires a team of trained auditors5)Deal with a large amount of information.6)Only evaluates record keeping .It only serve to improve documentation,not nursing care.AUDIT COMMITTE

Before carrying out an audit ,an audit committee should be formed comprising of a minimumof five members who are interested in

quality assuarance ,are clinically competent and able to work together in a group.It is recommended that each member should review not more than 10 patients each month and that the auditor should have the ability to carry out an audit in about15 min.If there are less than 50 dischrges per month,then all the records may be audited,if there are large number of records tobe audited ,then an auditor may select 10% of discharges.

Training for auditors should include the following.:

a.A detailed discussion of the seven components,

b)A group discussion to see how the group rates the care received using the notes of a patient who has been discharged,these should be anonymous and should reflect a total period of care not exceeding two weeks in length .

c)Each individual auditors should then undertake the same exercise.This is followed by the meeting of the whole committee who compare and discuss its findings, and finally reach a consensus of opinion on each of the components.

STEPS TO PROBLEM SOLVING PROCESS IN PLANNING CARE :

a. Collects patient data in a systematic manner,1. includes description of patients pre-hospital routines,2. has information about the severity of illness,3. has information regarding lab tests,4. has information regarding vital signs,5. Has information from physical assessment etc.b. States nurses diagnosis,c. Writes nursing orders,d. Suggests immediate and long term goals,e. Implements the nursing care plan,f. Plans health teaching for patients,g. Evaluates the plan of care

FUNCTIONS

Development of purposes and objectives.Establishing standards and criteria.Establishing guidelines for conducting auditDeciding upon auditing forcesInitiating audit process.Keeping up all audit committee meetings.RESPONSIBILITIES

Planning audit sessions and meetings.

Arrange for medical records to pull charts for retrospective and maintenance of audit procedure.Evaluating audit results in committee.Conducting audit process.Prepairing summaries of all audits.Teaching professional nursing personel the audit process.Assissting nursing staff in using audit results.Making recommendations.

RESPONSIBILITY OF A NURSE IN NURSING AUDIT

Persons responsible

The persons responsible for the Nursing audit are the professional nurses who can function as individual auditors.They may be associated closely with the client, be compleately unfamiliar with the client, or the group may comprise some nurses who know and some who do not know.

Task of the nurse

The first task of the auditors is to establish standards against which their observations will be measured.Although several nurses may be responsible for developing these standards,performing the audit or aspects of it can be delegated to various members of the group.

Frquency of audit

The frequency with which audits are taken can be determined by the group,according to the type of client whose care is to be audited.

Factors that should be remembered

Important factors in the conduct of an audit are that nurses should be convinced of its value,should develop standards and auditing instruments appropriate for the clients and should be motivated to continue to improve the auditing techniques for their own satisfaction andfor the continued improvement of the care given to the client.

PROBLEMS IN AUDITING

Lack of resources Personnel problems Unreasonable clients and attenders Improper maintenance Absence of well informed population absence of accreditation laws Legal regress Lack of incident review procedure Lack of good hospital information system Absence of survey condition routine Lack of nursing care records.

NURSING AUDIT: IDENTIFYING NOTIONS AND METHODS-RESEARCH NOTES

(Scarparo A F, Ferraz C A.)The present study aimed at identifying and analyzing the opinions of auditing experts who work within the context of nursing and systematizing trends regarding the notion,methods and purpose of nursing audits at present and over the next five years.In terms of methodology, the study was structured using the deiphi technique, type of prospective and consensual evaluation of trends, performed by the experts on the theme under investigation.results demonstrated that the current notion of nursing audit focuses on the accounting and financial elements,the financial maintenance of the hospital being kept in mind as well as the controlling activity or trying to identify incorrect hospital bills.In the future, however, the notion of auditing is expected to become associated with evaluating the quality of care,with the involvement of other areas that have an impact on it.

CONCLUSIONA profession concerns for the quality of its service, constitutes the heart of its responsibility to the public.An audit helps to ensure that the quality of nursing care desired and feasible is achieved.This concept is often reffered to as Quality assurance.

CHAPTER-III

STANDARDSStandard is an acknowledged measure of comparison for quantitative or qualitative value, criterion, or norm. A standard is a practice that enjoys general recognition and conformity among professionals or an authoritative statement by which the quality of practice, service or education can be judged. It  is also defined as a  performance model that results from integrating criteria with norms and is used to judge quality of nursing objectives, orders and methods

A standard is a means of determining what something should be. In the case of nursing practice standards are the established criteria for the practice of nursing. Standards are statements that are widely recognised as describing nursing practice and are seem as having permanent value.

A technical standard is an established norm or requirement. It is usually a formal document that establishes uniform engineering or technical criteria, methods, processes and practices. In contrast, a custom, convention, company product, corporate standard, etc. which becomes generally accepted and dominant is often called a de facto standard.

A technical standard can also be a controlled artifact or similar formal means used for calibration. Reference Standards and certified reference materials have an assigned value by direct comparison with a reference base. A primary standard is usually under the jurisdiction of a national standards body. Secondary, tertiary, check standards and standard materials may be used for reference in a metrology system. A key requirement in this case is (metrological) traceability, an unbroken paper trail of

calibrations back to the primary standard.

A technical standard may be developed privately or unilaterally, for example by a corporation, regulatory body, military, etc. Standards can also be developed by groups such as trade unions, and trade associations. Standards organizations often have more diverse input and usually develop voluntary standards: these might become mandatory if adopted by a government, business contract, etc.

The standardization process may be by edict or may involve the formal consensus of technical experts.

A nursing care standard is a descriptive statement of desired quality against which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe conduct, an aid to

professional performance.A nursing standard can be a target or a gauge. When used as a target, a standard is a planning tool. When used as a gauge against which to evaluate performance a standard is a control device.

Characteristics of Standard

Standards statement must be broad enough to apply to a wide variety of settings. Standards must be realistic, acceptable, attainable. Standards of nursing care must be developed by members of the nursing profession;

preferable nurses practising at the direct care level with consultation of experts in the domain. Standards should be phrased in positive terms and indicate acceptable performance good,

excellence etc. Standardsof nursing care must express what is desirable optional level. Standards must be understandable and stated in unambiguous terms. Standards  must be based on current knowledge and scientific practice. Standards must be reviewed and revised periodically. Standards may be directed towards an ideal ,ie,optional standards or may only specify the

minimal care that must be attained,ie, minimum standard. And one must remember that standards that work are objective, acceptable, achievable

and flexible.

Purposes of Standards

Setting standard is the first step in structuring evaluation system. The following are some of the purposes of standards.

Standards give direction and provide guidelines for performance of nursing staff. Standards provide a baseline for evaluating quality of nursing care Standards help improve quality of nursing care, increase effectiveness of care and

improve efficiency. Standards may help to improve documentation of nursing care provided. Standards may help to determine the degree to which standards of nursing care

maintained and take necessary corrective action in time. Standards help supervisors to guide nursing staff to improve performance. Standards may help to improve basis for decision-making and devise alternative system

for delivering nursing care. Standards may help justify demands for resources association. Standards my help clarify nurses area of accountability. Standards may help nursing to define clearly different levels of care.

Major objectives of publishing, circulating and enforcing nursing care standards are to:

1. improve the quality of nursing care,

2. decrease the cost of nursing, and

3. determine the nursing negligence.

Sources of Nursing Care Standards

It is generally accepted that standards should be based on agreed up achievable level of performance considered proper and adequate for specific purposes. The standards can be established, developed, reviewed or enforced by variety of sources as follows:

Professional organisation, e.g. Associations, TNAI, Licensing bodies, e.g. Statutory bodies, INC, Institutions/health care agencies, e.g.  University Hospitals, Health Centres. Department of institutions, e.g. Department of Nursing. Patient care units, e.g. specific patients' unit. Government units at National, State and Local Government units. Individual e.g. personal standards

Classification of Standards

There are different types of standards used to direct and control nursing actions.

1. Normative and Empirical Standards

Standards can be normative or empirical. Normative standards describe practices considered 'good' or 'ideal' by some authoritative group. Empirical standards describe practices actually observed in a large number of patient care settings. Here the normative standards describe a higher quality of performance than empirical standards. Generally professional organisations (ANA/TNAI) promulgate normative standards where as low enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.

2. Ends and Means Standards

Nursing care standards can be divided into ends and means standards. The ends standards are patient-oriented; they describe the change as desired in a patient's physical status or behaviour. The means standards are nursing oriented, they describe the activities and behaviour designed to achieve the ends standards. Ends (or patient outcome) standards require information about the patients. A means standard calls for information about the nurses performance.

3. Structure,Process and Outcome Standards

Standards can be classified and formulated according to frames of references (used for setting and evaluating nursing care services) relating to nursing structure, process and outcome, because standard is a descriptive statement of desired level of performance against which to evaluate the quality of service structure, process or outcomes.

 a. Structure Standard

A structural standard involves the 'set-up' of the institution. The philosophy, goals and objectives, structure of the organisation, facilities and equipment, and qualifications of employees are some of the components of the structure of the organisation, e.g. recommended relationship between the nursing department and other departments in a health agency are structural standards, because they refer to the organisational structure in which nursing is implemented. It includes people money, equipment, staff and the evaluation of structure is designed to find out the effectiveness ,degree to which goals are achieved and efficiency in terms of the amount of effort needed  to achieve the goal.

The structure is related to the framework, that is care providing system and resources that support for actual provision of care. Evaluation of care concerns nursing staff, setting and the care environment. The use of standards based on structure implies that if the structure is adequate, reliable and desirable, standard will be met or quality care will be given.

b. Process Standard

Process standards describe the behaviours of the nurse at the desired level of performance The criteria that specify desired method for specific nursing intervention are process standards. A process standard involves the activities concerned with delivering patient care.These standards measure nursing actions or lack of actions involving patient care.The standards are stated in action-verbs, that is in observable and measurable terms.eg :the nurse assesses", "the patient demonstrates". The focus is on what was planned, what was done and what was communicated or recorded. Therefore, the process standards assist in  measuring the degree of skill, with which technique or procedure was carried out, the degree of client participation or the nature of interaction between nurse and client.In process standard there is an element of professional judgement determining the quality or the degree of skill. It includes nursing care techniques, procedures, regimens and  processes.

c.Outcome Standards

Descriptive statements of desired patient care results are outcome standards because  patient's results are outcomes of nursing interventions. Here outcome as a frame of reference for setting of standards refers to description of the results of nursing activity in terms of the change that occurs in the patient. An outcome standard measures change in the patient health status. This change

may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care.

LEGAL SIGNIFICANCE OF STANDARDS

Standards of care are guidelines by which nurses should practice.If nurses do not perform duties within accepted standards of care,they may place themselves in jeopardy of legal action.Malpractice suit against nurses are based on the charge that the patient was injured as a consequence of the nurses failure to meet the appropriate standards of care.

To recover losses from a charge of malpractice, a patient must prove that:

1. a patient-nurse relationship existed such that the nurse owed to the patient a duty of due care,

2. the nurse deviated from the appropriate standard of care,3. the patient suffered damages,

STANDARDS FOR CORONARY CARE UNIT

A CCU is defined as a designated ward of a hospital which is specifically staffed and equipped to provide observation, care and treatment to patients with acute cardiac problems, such as acute myocardial infarction and unstable angina and who may have undergone interventional procedures from which recovery is possible. The CCU provides special facilities and utilises the expertise and skills of medical, nursing and other staff trained and experienced in the management of these conditions.

The duration of stay in CCU is collected to provide information on the profile of patients transferred between hospitals due to their need for a CCU bed, and to substantiate the need for such transfers. These data will support the extension of the Critical Care Inter-Hospital Transfer (CCIHT) Program to CCUs. Duration of stay in CCU by patients not transferred from another hospital is also required and will be used as comparative data and modelling for future funding options.

Intensive care is appropriate for the following categories of patient:

Patients requiring advanced respiratory support alone.Patients requiring support of two or more organ systemsPatients with chronic impairment of one or more organ systems sufficient to restrict normal activity and who require support for an acute reversible failure of another organ system.

High dependency care is appropriate for the following categories of patient:Patients requiring support for a single failing organ system,but excluding those needing advanced respiratory support. Patients requiring a level of observation or monitoring not possible on a general ward.

High dependency care requires a level of care intermediate between that available on a general ward and that on an ICU. A high dependency unit (HDU) should be able to provide monitoring and support to patients with, or at risk of developing, acute or acute-on-chronic single organ failure. It should not manage patients requiring multiple organ support or mechanical ventilation.

DESIGN

GENERAL CONSIDERATION

Standard 1:The design phase of the coronary care facility will be directed by a multi disciplinary team.

Standard 2 :The floor plan will be designed based on the primary and expanded design teams recommendations for patient rooms,traffic pattern,nursing stations, support areas,administerative and educational space,public space needs,standards of care.

PATIENT ROOM AND AREA DESIGN

Standard 3:Patient bed area will be designed with adequate space and will provide a supportive environment that minimizes stress.This may be done with either “open” or “closed” unit configuration.

Standard 4:Patient bed area will be designated to provide for direct or indirect visualisation,facilitate detection of patient status changes and enhance implementation of therapeutic measures and documentation of patient care under routine or emergencic circumstances.

Standard 5 :The power, oxygen,compressed air,vaccum,lighting and thermal systemswill support the needs of the patients and critical care team members under normal and emergency situations and will meet or exceed regulatory and accreditation agency codes and regulations.

Standard 6:Physiologic monitoring capability will provide for display of waveforms and digital values for ECG, and arterial,venous ,intracardiac and intracranial pressures.

Standard 7: Computer applications should be provided for data input,retrival, and analysis.

Standard 8 :Isolation room with separate washing and gowning facilities will be provided within the CCU.

Standard 9 : A mechanism must be provided to all for constant visual observation of the patient.

Standard 10 :Provisions should be made for rapid easily accessible information exchange and communication within the unit and hospital.

Standard 11 :The unit will provide the ability to continuously monitor patients waveforms and digital values for ECG, and should provide for continous selected respiratory,arterial,venous,intracardiac and intracranial monitoring.

Standard 12 :The unit will be designed to provide adequate space for clerical duties,record preparation and charting.

Standard 13 :Work areas and storage of coronary care supplies should be in location such that they are readily accessible to nursing and physician staff.

Standard 14 :If a central station is included, its design will provide for a comfortable area of sufficient size to accommodate those activities to be performed.

SUPPORT AREAS

Standard 15 : Coronary care units of more than 12 beds or clustered CCU, should have a separate receptionist area.

Standard 16 :An optional special procedures room must be designed with adequate space and support devices.

Standard 17 :Separate clean and dirty utility rooms with separate access doors will be provided.

Standard 18 :24 hr pharmacy services should be available.

Standard 19 :24 hr pharmacy service should be available.

Standard 20:A store room will be provided for securing patient care equipment.

Standard 21:A staff lounge with toilet facilities should be provided.

Standard 22:A nourishment preparation area should be provided.

Standard 24:House keeping facilities will be provided near the utility roomsor immediately outside the coronary care unit.

PATIENT AREA The unit should be fully air-conditioned, although windows should be openable when the system is non operational. The patient area should contain an open area for several beds together, plus at least one cubicle.Thereafter, a minimum ratio of 1 cubicle:6 bed spaces is required. However, in some circumstances, the ratio may need to be much higher There may be an increasing need for cubicles because of the growth in numbers of immunocompromised patients or infectious cases (e.g. methicillinresistant Staphylococcus aureus).Various physical arrangements are possible. For convenient management there should be 4-7 beds in the open area, with at least 20m2 floor area for each bed and 2.5m of unobstructed corridor space beyond the working area Adequate separation of beds is a major aspect of infection control. In any multi-bed area, beds should be positioned to maximise patient privacy. This may preclude 'facing' beds. Siting and method of provision of services (e.g. gantry, stalactite) may alter the floor area required .

CENTRAL STATION/SERVICES

The following management functions need to be accommodated within or adjacent to the patient area, although their precise distribution may vary.

a) CommunicationThe management base/nurses' station must be sited in such a way that it commands a clear, unobstructed view of the whole of the main patient area.This base serves as the central communications area for all the clinical management of the patients.The central station requires at least 4 telephone extensions, all with STD facility. They must be capable of receiving direct-dial incoming calls without need for hospital switchboard. For national calls, no block requiring switchboard intervention should exist. At least two lines must be able to receive e-mail or fax transmissions, and be of ISDN standard. Call hold, transfer, group pickup, and conference facilities should be available on each phone, or twin or triple extensions must be available. Other facilities, e.g. camp-on-busy, call divert, hunt group, are extremely useful in busy units. The communication facilities are based upon a maximum unit size of 8 beds.

A personnel locator system for all parts of the complex may complement or replace some telephones but each patient area requires an internal telephone extension.Considerable noise will be generated in this area and sound deadening must be considered. Solutions may include telephone cubicles or telephones fitted with lights rather than bells.The increasing quantity of electronic communications means that the nurses station must be large enough to incorporate two visual display units b) MonitoringVisual display units and other equipment should allow an overview of bedside monitor activity, access to the hospital information systems and local area networks. c) Drugs: Controlled drug storage, drug cupboards or trolleys, drug refrigerators

Because of the large quantities and ranges of drugs required in large units, a drug cupboard may be of 'walk-in' size. For security reasons, walk-in drug cupboards should have glass walls or large windows. Consideration should be given to the need for air-conditioning or temperature control when a number of refrigerators are in operation. Refrigerators may be needed to store of large volumes of pre-packed parenteral nutrition bags (3-4L each). Intravenous and haemofiltration fluids must be stored in an adjacent area. Some fluids may require storage at higher temperatures (e.g. haemofiltration fluids, urological irrigation fluids etc.) and require a large warming cabinet. Microwave warming is not recommended.d) Storage of notes, radiographs, request forms, and other medical stationeryFacilities are needed for writing and for multiple radiograph viewing (e.g. roller type viewers), but these may be sited outside the patient area for example in the Medical Office. In future, digital radiograph viewing facilities may be available. Requirements for their installation should be discussed with departments of clinical imaging. It is sensible to install structural cabling for future increases in electronic communication in any new or refurbished facility. Alternatively, all cables should be routed via conduits, making additional cabling a relatively simple 'pull through'.e) Blood refrigeratorA blood refrigerator should be available in the ICU unless a blood store is available in the immediate locality, or another means for immediate delivery of blood (vacuum tube system) is available. Use of such a refrigerator will be governed by national and local blood transfusion service regulations.f) Cardiac arrest/emergency trolleyIn some units, consideration should be given to storage space for ultrasound machines.g) X-ray machine parking, with electrical socket for chargingIn some units, consideration should be given to storage space for ultrasound machines.h) Cardiac arrest/emergency trolleyA second cardiac arrest trolley/defibrillator should be sited at a distant part of the unit, and units with more than 6 beds should have a third cardiac arrest trolley. At least one defibrillator must be equipped for external cardiac pacing.i) Emergency medical equipmentThis should be kept in the management area and should include emergency airway equipment for tracheostomy, bronchoscopy and thoracotomy, high power torches and spare cylinder spanners.j) Storage of shared medical examination equipmentThis may include neurological examination equipment, nerve stimulators, respirometers, peak flow or inspiratory power meters.k) Safety facilitiesWithin-ICU facilities needed in the event of a major failure of external power sources should be close to the management area. These should include large (size G or J) compressed oxygen and air cylinders and appropriate regulators, terminal connectors, flow meters and vacuum adapters, battery operated portable lights, electric air compressor and vacuum pumps. The backup services should be able to support patients for at least 1 hour. Requirements for emergency electrical supplies etc. .L)Security control

The increasing need for security makes it likely that the central station will need to have means of control of access to the ICU site.

STORAGE Adequate storage space outside the patient area is essential. EEC directives on manual handling make the means of storage and access increasingly important. Much heavy, or bulky, but mobile equipment (e.g. ventilators, drip stands) requires storage and cannot be placed on shelves.Deep storage is inappropriate, because items may be easily lost at the back of shelves. Furthermore, only small quantities of equipment can be stored on shelves above arm height (1.5m).The storage space suggested in HBN 27 is inadequate for units with more than 4 beds as it does not increase space pro-rata with bed numbers. This applies to areas referred to in HBN 27 as 'bulk' storage, 'clean' utility, 'dirty'utility, disposal hold, linen bay, clinical equipment store, furniture store, equipment service room, laboratory and lobby.If possible, storage should be approachable both from the patient area and from the supply route, which should be separate from the patient area. The storage area should be a maximum of 30m from the furthest bed.Storage should consist of:a) Storage for consumables (CSSD items, plastic and electronic disposables of all types). The floor area should be at least 5m2 per bed, with shelves, cupboards and drawers. This may be divided between an immediate store adjacent to the patient area, andb) a back-up store. Whatever, method is suitable, deep storage should be avoided. Consumables are often small with a relatively short half-life.c) Storage for equipment (e.g. ventilators, dialysis and haemofiltration machines,traction equipment, monitoring apparatus, infusion pumps and syringe drivers, drip stands,trolleys, blood warmers, portable suction apparatus). In larger units, a separately located electrical equipment store, workshop and a bulk furniture store for beds, traction frames, etc. may be preferred.d) A total floor area of at least 5m2 per bed is needed, with shelves, cupboards, drawers, wall rail and bins. The furniture store requiresf) Storage for linen. This should be adjacent to the patient area. 2m2 of floor space is needed for each bed. This area may bereduced if laundry turn-around is rapid (twice daily top-up service).g) X-ray/imaging equipment bay close to or within the complex.Floor area should exceed 4.5m2. Dirty Utility RoomFor bedpan storage and destruction and dirty dressings disposal. An area with bench space and sink for dismantling dirty ventilators etc. may be needed,depending on unit sterilising policy. These areas may be separate: a total area of 20m2 is needed.A separate area is required for storage of bagged clinical waste. The floor space required will be at least 2m2, but may be greater depending upon frequency of waste collection. clean utility roomLARGER units will need separate accommodation for laying up trolleys, etc. At least 10m2 is needed, adjacent to the immediate consumables store. Local policies may allow location of this space in the main ward area.

NURSES' OFFICE

At least 15m2 is required with separate telephone extensions, computer,hospital information system terminal and notice boards. The senior sister requires a separate office (10m2) dependent upon the total size of the unit, or its staff numbers. Specialist nurses, e.g. training nurse, research nurse, may require office space.

MANAGER'S OFFICE An office of 15m2 is needed as a business office close to the intensive care complex. This requires telephone (with all facilities for direct dial, hold, transfer etc.), computer terminal and fax.

MEDICAL OFFICE At least 15m2 is needed, with separate telephone extension, computer terminal, hospital information system, and intercom terminal.At least 15m2 is needed for the clinical director's office. This should be separate from the consultant's office. Facilities similar to the consultant'soffice are needed together with e-mail, fax and an additional telephone.

AUDIT OFFICE At least 10m2 is required for the audit assistant. This office requires two telephone points, one of which will be used for computer modem. This room will house at least two computers and a significant amount of sensitive data.Security aspects must considered.

STAFF ROOMS a) A staff rest-room with, communications systems, television and radio should be provided. Kitchen facilities may be integral or preferably immediately adjacent .The beverage bar should be equipped to reheat food, e.g. with a microwave oven. A food refrigerator should be available. A plumbed in dishwasher is useful. An ice-making machine somewhere in the complex is useful, but local Health and Safety regulations may override the provision of these machines in the hospital complex. If this is the case, there must be alternative means of cooling severely pyrexial(patients. The staff rest room should be provided with external windows and comfortable seating.

An area of not less than 21m2 should be provided and increased pro-rata from 8 beds (and equivalent staff) upwards (3m2/2 beds). The area should be segregated from the relatives' room and through routes to the main ward area.Security precautions are necessary.b) Staff require facilities for changing, lockable lockers, showers and toilets. At least one wash hand basin and a drinking water facility is necessary. At present, the ratio of female:male nursing staff in many ICUs is 2:1. Changing facilities should be provided on the unit at the rate of about 0.75m 2/nurse with a minimum of 15.5m2 for female staff and 7.5m2 for male. Separate staff shower facilities and WCs should be available in each changing room. Both the changing room and lockers must be individually lockable. These requirements may be modified if the hospital has centralised changing facilities for nursing staff.

DOCTOR'S ON-CALL ROOM/STUDY

The bedroom/study should have a floor area of 15m2, and be equipped with a bed, wash hand basin, shower, WC, wardrobe, telephone extension, intercom terminal and television. A secure locker must be available. There must be a desk and bookcase to allow study or preparation of notes or projects. A secure window and outside view is needed: it must be quiet. Although it needs to be close to the patient area and be within the unit complex, for privacy it should be segregated and out of direct routes between unit entrance, visitors' sitting room and the patient areas. The room must be protected from noise by positioning, the use of double doors and of sound reducing materials.

MEDICAL EQUIPMENT WORKSHOP SATELLITE FACILITY This requires a floor area of 15m2 in addition to any storage area. Workbench,storage space, sink, compressed air, oxygen and vacuum terminals, and scavenging outlet are needed. There should be at least six electrical outlets,increased according to the role of the workshop.Some ICUs may use the facility only for minor repairs, adjustment, assembly and testing of equipment, whereas others may consider it appropriate to perform all servicing and repairs in an ICU workshop. Under these circumstances relocation of area from the main workshop may be needed: an area as large as 50m2 (and office space) may be needed for large ICUs. CONCLUSION

standard is an established norm or requirement. It is usually a formal document that establishes uniform engineering or technical criteria, methods, processes and practice

CHAPTER IV

INTRODUCTION

Policy is a plan , direction or action goal. A policy is a broad statement formulated to provide guidance in decision making at lower levels of management. It defines the area or limits within which decisions are made. Policies are stated in long range terms that express or stem from the philosophy of the organisation.

A policy is typically described as a principle or rule to guide decisions and achieve rational outcome. The term is not normally used to denote what is actually done, this is normally referred to as either procedure or protocol. Whereas a policy will contain the 'what' and the 'why', procedures or protocols contain the 'what', the 'how', the 'where', and the 'when'. Policies are generally adopted by the Board of or senior governance body within an organisation where as procedures or protocols would be developed and adopted by senior executive officers.

The term may apply to government, private sector organizations and groups, and individuals. Presidential executive orders, corporate privacy policies, and parliamentary rules of order are all examples of policy. Policy differs from rules or law. While law can compel or prohibit behaviors (e.g. a law requiring the payment of taxes on income), policy merely guides actions toward those that are most likely to achieve a desired outcome.

Policy or policy study may also refer to the process of making important organizational decisions, including the identification of different alternatives such as programs or spending priorities, and choosing among them on the basis of the impact they will have. Policies can be understood as political, management, financial, and administrative mechanisms arranged to reach explicit goals

DEFINITIONS

According to Mc Farland policies are planned expressions of the company’s official attitudes towards the range of behaviour within which it will permit or desire its employees to act.

According to Fippo 1976 policy is a man made rule of predetermined course of action that is established to guide the performance of work toward the organisation objectives. It is a type of standing plan that serves to guide subordinates in the execution of their tasks.

CHARACTERISTICS

Policies are routes to the administration of objectives. While objectives provide destination to be reached, policies provide broad pathways for reaching them.A policy is a standing plan that guides the people for a long period.Policies are broad in scope and flexible.Policies help to direct individual behaviour, the organisations missions and defines broad limits and desired outcomes of commonly occurring situations.Policies are restrictive in nature, because they define the boundary within which decisions ought to be made. Policies are permissive because the subordinates are allowed some degree of freedom to exercise initiative and discretion but within limits.

Impact

Intended effects

The intended effects of a policy vary widely according to the organization and the context in which they are made. Broadly, policies are typically instituted to avoid some negative effect that has been noticed in the organization, or to seek some positive benefit.

Corporate purchasing policies provide an example of how organizations attempt to avoid negative effects. Many large companies have policies that all purchases above a certain value must be performed through a purchasing process. By requiring this standard purchasing process through policy, the organization can limit waste and standardize the way purchasing is done.

The State of California provides an example of benefit-seeking policy. In recent years, the numbers of hybrid cars in California has increased dramatically, in part because of policy changes in Federal law that provided USD $1,500 in tax credits (since phased out) as well as the use of high-occupancy vehicle lanes to hybrid owners (no longer available for new hybrid vehicles). In this case, the organization (state and/or federal government) created an effect (increased ownership and use of hybrid vehicles) through policy (tax breaks, highway lanes).

Unintended effects

Policies frequently have side effects or unintended consequences. Because the environments that policies seek to influence or manipulate are typically complex adaptive systems (e.g. governments, societies, large companies), making a policy change can have counterintuitive results. For example, a government may make a policy decision to raise taxes, in hopes of increasing overall tax revenue. Depending on the size of the tax increase, this may have the overall effect of reducing tax revenue by causing capital flight or by creating a rate so high that citizens are deterred from earning the money that is taxed. (See the Laffer curve.)

The policy formulation process typically includes an attempt to assess as many areas of potential policy impact as possible, to lessen the chances that a given policy will have unexpected or unintended consequences. Because of the nature of some complex adaptive systems such as societies and governments, it may not be possible to assess all possible impacts of a given policy.

Policy cycle

In political science the policy cycle is a tool used for the analyzing of the development of a policy item. It can also be referred to as a "stagist approach". One standardized version includes the following stages:

1. Agenda setting (Problem identification)2. Policy Formulation3. Adoption4. Implementation5. Evaluation

An eight step policy cycle is developed in detail in The Australian Policy Handbook by Peter Bridgman and Glyn Davis: (now with Catherine Althaus in its 4th edition)

1. Issue identification2. Policy analysis3. Policy instrument development4. Consultation (which permeates the entire process)5. Coordination6. Decision7. Implementation8. Evaluation

The Althaus, Bridgman & Davis model is heuristic and iterative. It is intentionally normative and not meant to be diagnostic or predictive. Policy cycles are typically characterized as adopting a classical approach. Accordingly some postmodern academics challenge cyclical models as unresponsive and unrealistic, preferring systemic and more complex model.

Content

Policies are typically promulgated through official written documents. Policy documents often come with the endorsement or signature of the executive powers within an organization to legitimize the policy and demonstrate that it is considered in force. Such documents often have standard formats that are particular to the organization issuing the policy. While such formats differ in form, policy documents usually contain certain standard components including:

A purpose statement, outlining why the organization is issuing the policy, and what its desired effect or outcome of the policy should be.

An applicability and scope statement, describing who the policy affects and which actions are impacted by the policy. The applicability and scope may expressly exclude certain people, organizations, or actions from the policy requirements. Applicability and scope is used to focus the policy on only the desired targets, and avoid unintended consequences where possible.

An effective date which indicates when the policy comes into force. Retroactive policies are rare, but can be found.

A responsibilities section, indicating which parties and organizations are responsible for carrying out individual policy statements. Many policies may require the establishment of some ongoing function or action. For example, a purchasing policy might specify that a purchasing office be created to process purchase requests, and that this office would be responsible for ongoing actions. Responsibilities often include identification of any relevant oversight and/or governance structures.

Policy statements indicating the specific regulations, requirements, or modifications to organizational behavior that the policy is creating. Policy statements are extremely diverse depending on the organization and intent, and may take almost any form.

Some policies may contain additional sections, including:

Background, indicating any reasons, history, and intent that led to the creation of the policy, which may be listed as motivating factors. This information is often quite valuable when policies must be evaluated or used in ambiguous situations, just as the intent of a law can be useful to a court when deciding a case that involves that law.

Definitions, providing clear and unambiguous definitions for terms and concepts found in the policy document

Typologies

Policy addresses the intent of the organization, whether government, business, professional, or voluntary. Policy is intended to affect the 'real' world, by guiding the decisions that are made. Whether they are formally written or not, most organizations have identified policies.

Types of policy analysis include:

Causal (resp. non-causal) Deterministic (resp. stochastic, randomized and sometimes non-deterministic) Index Memoryless (e.g. non-stationary) Opportunistic (resp. non-opportunistic) Stationary (resp. non-stationary)

CLASSIFICATION

1. IMPLIED POLICIES- They are neither written nor expressed verbally, have usually developed over time and follow a precedent.

Eg:- employees should be encouraged to take part in community activities, regional and national health care activities.2. EXPRESSED POLICIES:-they are delineated verbally or in writing.Eg:- policy of leave facility, uniform etc.

Distributive policies

Distributive policies extend goods and services to members of an organization, as well as distributing the costs of the goods/services amongst the members of the organization. Examples include government policies that impact spending for welfare, public education, highways, and public safety, or a professional organization's

Regulatory policies

Regulatory policies, or mandates, limit the discretion of individuals and agencies, or otherwise compel certain types of behavior. These policies are generally thought to be best applied when good behavior can be easily defined and bad behavior can be easily regulated and punished through fines or sanctions. An example of a fairly successful public regulatory policy is that of a speed limit.

Constituent policies

Constituent policies create executive power entities, or deal with laws. Constituent policies also deal with Fiscal Policy in some circumstances.

Miscellaneous policies

Policies are dynamic; they are not just static lists of goals or laws. Policy blueprints have to be implemented, often with unexpected results. Social policies are what happens 'on the ground' when they are implemented, as well as what happens at the decision making or legislative stage.

When the term policy is used, it may also refer to:

Official government policy (legislation or guidelines that govern how laws should be put into operation)

Broad ideas and goals in political manifestos and pamphlets A company or organization's policy on a particular topic. For example, the equal

opportunity policy of a company shows that the company aims to treat all its staff equally.

The actions the organization actually takes may often vary significantly from stated policy. This difference is sometimes caused by political compromise over policy, while in other situations it is caused by lack of policy implementation and enforcement. Implementing policy may have unexpected results, stemming from a policy whose reach extends further than the problem it was originally crafted to address. Additionally, unpredictable results may arise from selective or idiosyncratic enforcement of policy.

ICU policiesThre should be written policies for the intensive coronary care units which will guide the personnel working there.All these policies should be made known to all personnel.In the policy making body ,there should be representation from administerative team,medical team and nursing team.The policies may be written regarding the following.

Admission of patient.AdmiSsion of medico-legal cases.Discharge of the patients.Medical consultation.Protocoals for administration of drugs,operation of equipments, and carrying out the procedures.Managing the emergency situation.The policies should statehow much the nurses do in such emergencies as Bradycardia,ventricular arrhythmiasInfection controlMaintanence of records.Payments.Visiting of patient

POLICIES IN INTENSIVE CORONARY CARE UNIT

Operational Policies

Clinical ManagementTwo different patterns of clinical management are seen in the UK, and the actual arrangement adopted should be defined, agreed and understood by all the consultants concerned. In either case routine

management should be prescribed and supervised by unit medical staff. Decisions of a more specific nature should be taken in consultation with the referring clinician. 'Closed Unit': Intensive care consultant completely responsible for clinical management The intensive care consultant(s) may have complete clinical responsibility for the care of patients admitted to the unit. They take over when the patient is admitted and may transfer care to another appropriate consultant at the time of discharge. In this case, the consultant who originally admitted the patient to ther specialities may also be invited to give advice.

.'Open Unit': Clinical management remains responsibility of admitting Consultant Patients are admitted to the ICU under the care of their admitting consultants and remain so throughout their stay. The ICU consultants are usually deemed to be in consultation but the extent of their responsibility will be agreed locally.Other consultants may also be called in consultation according to need.This arrangement is better suited to general ICUs serving a wide range of admitting specialties, none of which could sustain their own dedicated unit.Units in which the intensive care consultant has had a high degree of autonomy and control of patients in the intensive care environment have been consistently shown to produce better patient outcomes

Administrative responsibilityThe apportionment of administrative responsibility among the intensive care consultants, and between them and the senior nurse, should be defined. Theintroduction of a business management approach, if not already in use, should be considered in the definitions of areas of responsibility.The main areas concerned are operational policies, equipment management,audit, financial management, staffing, safety (including Health and Safety at Work), research and teaching, hospital and medical administration, liaison with other departments, Divisions, Directorates, and purchasers.

Admission and discharge policyA formal policy for admission and discharge of patients must be adopted. Admissions should be agreed with the consultant in charge of the unit at the time, particularly when all staffed beds are occupied. Non-unit staff, no matter how senior, should not be permitted to order patients into the unit. Every case must be considered on its merits. Many units do not admit patients who are on the point of death. Conversely, only in exceptional circumstances will a patient whose death is imminent be transferred out of the unit.When a patient is ready for discharge it is the responsibility of the admitting clinician to find a bed. At discharge, the ICU is responsible for handover of the patient to the receiving team, and ensuring that appropriate therapies are continued. Should the patient die, the ICU must notify admitting and co-opted teams and the patient's family doctor as soon as possible, i.e. immediately during office hours or immediately the following morning if death occurs atnight or weekend.

Whatever approach is made, it is necessary to provide a clear audit trail,necessary for generation of appropriate medical statistics.

Therapeutic PoliciesTo avoid confusion and in the interests of training, a consistent approach to common therapeutic procedures should be adopted within the unit. For example, insertion of a chest drain should be carried out in the prescribed manner in all patients, unless there is a special reason for not doing so. Similarly the technical arrangements for continuous infusion of drugs such as inotropes should be consistent.The actual writing of prescriptions should preferably be the responsibility of the intensive care resident. A standard handbook describing these policies should be readily available to all staff, preferably on disc.

Regular (6 monthly) updating or review is appropriate. Local policies and procedures established by a Drug and Therapeutics Committee should be adhered to and diversions from such policies acknowledged by the Committee. Investigational PoliciesUniform procedures should be adopted for routine investigations. For example the timing of 24-hour urine collections, the method of calculating nitrogen losses and the frequency of repetition of routine biochemical tests should all be consistent. Automated analysis profiles may be arranged with the pathology laboratories for admission and daily investigations. Specific profiles of investigation should also be agreed with the laboratory for common emergencies, e.g. investigation of coagulopathy following massive transfusion. In order to standardise urine collections it is convenient to choose the start of the 'ICU day' and to begin this at either 07.00 or 08.00 related to the start of nursing shifts and the opening time of the pathology laboratory.

The arrangements for collecting, transmitting and reporting on laboratory samples must be fast, reliable and clearly understood. Laboratories should give appropriate priority to samples from ICUs. Even when an ICU is situated adjacent to the main pathology laboratory, a unit should have its own laboratory for certain urgent estimations and near patient investigations such as blood gas analysis, electrolytes, haematocrit and osmometry. If the laboratory is distant or off-site this need becomes essential. Any within-ICU laboratory must be subject to regular maintenance and quality control testing, preferably by the main pathology service. This may be carried out by the ICU staff under the supervision of the pathology service.Microbiological investigations, frequency of samples, surveillance sampling should be agreed for routine patients and those with specific diagnoses, e.g. investigation of pneumonia in an immunocompromised patient. Investigational policies should be agreed with consultants in, for example,laboratories and imaging departments.

Infection Control policiesWith the concurrence of the consultant microbiologist and infection controlteam, infection control procedures should be agreed and enforced regarding:a) antibiotic policyb) clothing of staff and visitorsc) hand washingd) sterilisatione) aseptic precautions for invasive proceduresf) use of disposablesg) filtering of patients' respired airh) changing of catheters, humidifiers, ventilator tubing and other equipmentI) isolation of at-risk or infected patientsj) cleaning of the unitIncreasing use of disposable equipment leads to problems with disposal of clinical waste. Hospital incinerators may be reaching their maximum capacity,and local authority disposal systems may also be under pressure. Before the introduction of additional use of disposables, the mechanisms for disposal should be discussed with the providers of local facilities.

In control of infection, discipline and behaviour is more important than design.Design should be such as to encourage discipline and appropriate behaviour:an absence of sink will reduce the possibility of hand washing, but an abundance of sinks will not necessarily ensure that this behaviour is adopted.

CONCLUSION

A policy is typically described as a principle or rule to guide decisions and achieve rational outcome. The term is not normally used to denote what is actually done, this is normally referred to as either procedure or protocol. Whereas a policy will contain the 'what' and the 'why', procedures or protocols contain the 'what', the 'how', the 'where', and the 'when'. Policies are generally adopted by the Board of or senior governance body within an organisation where as procedures or protocols would be developed and adopted by senior executive officers.

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